Balance billing, also known as “surprise billing,” is when a patient receives a bill for the difference between the amount providers bill for their services and the amount paid by the patient’s health plan. Often, this balance is unexpectedly large. Balance billing usually occurs when patients are unaware that a provider is out of network or when they receive emergency services and are unable to choose the provider.
The Balance Billing Protection Act goes into effect on January 1, 2020, and generally prohibits health care providers and facilities from balance billing patients for certain services obtained on or after January 1, 2020. Proponents believe it will prevent surprise bills and remove consumers from payment disputes between insurers and non-contracted providers or facilities.
There’s a lot to know about how this new law affects Kaiser Permanente members. Below are answers to some frequently asked questions. For more information, contact your sales executive or account manager.
What services are affected by this Washington state law?
The law applies when a patient receives emergency services from an out-of-network provider or facility, or when a patient receives surgical or ancillary services from an out-of-network provider at an in-network hospital or in-network ambulatory surgical facility. In addition to surgery, ancillary services include anesthesiology, pathology, radiology, laboratory, and hospitalist services.
Does this law apply to all types of health plans?
No. The law doesn’t apply to Medicare health plans, federal employee health plans, or certain self-funded group health plans. Eligible self-funded group health plans must notify the Washington state Office of the Insurance Commissioner and Kaiser Permanente if they wish to participate.
For the services described in this law, what is the patient’s payment responsibility?
The patient is only responsible for their applicable in-network cost-sharing amount. If the patient has paid a provider or facility more than their in-network cost-sharing amount for the services described in this law, the provider or facility must refund any overpayment within 30 days.
What should members do if they receive a balance bill for services described in this law?
Members should contact Kaiser Permanente Member Services. They can verify claims processing and out-of-pocket expenses with the member, then submit a request for the provider to be contacted.